HARASSMENT SUBMISSION FORM

First & Last Name of the Complainant *

Department

Today's Date *

mm/dd/yyyy

First & Last Name of the Accused *

Relationship of the Accused to the Complainant

Date of Incident *

mm/dd/yyyy

Where did the specific event occur? *

Please explain the events that occurred. *

How did you react to the situation?

Were there any witnesses to this specific event? *

*

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